One she called the ‘minister of love’. The other? He was the ‘minister of finance’.

Sold on the idea: Asiphe Ntshongontshi used the family calendar to keep track of when she took the HIV prevention pill. She lives in Masiphumelele outside Cape Town close to a youth centre and clinic that dish out the tablet.

Since the country’s rollout, less than a quarter of people who’ve started taking the HIV prevention pill are young women — despite high HIV rates.

Asiphe Ntshongontshi, 23, plants a small “X” on the family calendar hanging on a wooden wardrobe. Her parents think she’s tracking her period so that the hospitality student isn’t caught unaware when her “monthly visitor” hits.

They’re wrong.

Every evening the Ntshongontshi family religiously bond over dinner and television. Like most Fridays, Ntshongontshi’s favourite soapie, Generations: The Legacy, ends with a cliffhanger:

“Surprise, surprise, Jack,” the soapie character Zitha announces from the screen in the family’s home. She’s just escaped death from Jack’s hitman, leaving her rival shocked. Brandishing a gun, Zitha bursts into an evil chuckle:

“There’s only one person dying tonight, and that’s you.”

As the credits begin to roll, Ntshongontshi’s cellphone bleeps out its usual alert — a signal for another ritual.

It’s a routine only she knows about. It’s time to take her daily pill.

Ntshongontshi walks to the kitchen and runs the water to wash the day’s dishes. As water pours into the basin, she fills up a glass of water and, secretly, pops a large, blue pill into her mouth.

PrEP comes in the form of a tablet called Truvada, which contains two antiretroviral (ARV) drugs, emtricitabine and tenofovir. Studies have shown that, when the pill is taken daily, Truvada can reduce a woman’s chances of contracting HIV by more than 90%.

But Ntshongontshi has to keep her secret to herself.

She explains: “I don’t want my parents to think that I am a naughty child.”

After school special: The Desmond Tutu HIV Foundation’s offices sit across the street from the local high school in Masiphumelele. Learners come to get extra tutoring, use the computer centre or play pool and grab a bite to eat. And while they do, staff get the chance to run health promotion programmes. (David Harrison)

Across the street, the local high school has just finished for the day. Dozens of pupils in navy and white uniforms are making their way to the large youth centre that sits adjacent to the foundation’s offices.

Once they’ve crossed the gravel road, pupils head to the centre’s reception where they greet a trio of receptionists before placing their index fingers on a digital fingerprint reader. A bright flash of light from the scanner records their attendance and registers a point, or a “Tutu”, in the student’s account at the centre. Twenty-four Tutus buy a sandwich and juice.

Sign up to use the organisation’s computers next to the pool tables or extra tutoring sessions and you can rack up another handful of points. If you visit the in-house youth clinic or take an HIV test, you can see as many as 100 Tutus tumbling into your account.

In the hall next door, a large colourful mosaic of the foundation’s namesake, Archbishop Emeritus Desmond Tutu, hangs on the wall. Underneath the Arch’s smiling gaze, staff hold pop-up sessions with young people about sexual and reproductive health or new programmes.

At the time, she was struggling to afford clothing. It wasn’t something her parents had a budget for and she was tired of wearing and washing the same clothes every week. Ntshongontshi had been in a longterm relationship with her boyfriend, but he wasn’t in a position to help either. So she turned elsewhere, finding a man 10 years her senior.

Her boyfriend was her “minister of love”. The other? “The ‘minister of finance’,” she explains.

Ntshongontshi is sitting on a steel chair next to a table in the boardroom of the centre.

“As a person, you feel that this partner is just going to give me love. He’s not earning that much.”

She touches her long dreadlocks.

“Then I would have my eyes open for another guy that is going to provide me with money — ‘the minister of finance’.”

But there was a price for the “minister of finance’s” support.

“Obviously, when he started giving me money, maybe after four months, he demanded sex without a condom,” Ntshongontshi explains.

“I couldn’t say no because he gave me money.”

Ntshongontshi chats with a neighbour outside her home. For years, campaigns have been telling young women that they are at a higher risk of contracting HIV but a new study shows how we see our HIV risk is far more personal than many messaging campaigns may have taken into account.

Age gaps can also amplify inequalities in sexual relationships, making it more difficult for younger women to negotiate safe sex, researchers argue. To combat this, the country’s national HIV plan says that programmes to reduce young women’s risk of contracting HIV — such as PrEP — need to be rolled out. The strategy hopes this will reduce new infections among adolescent girls and young women from 1 300 a week in 2017 (according to figures from the Human Sciences Research Council) to less than 800 a week by the end of 2022.

In Masiphumelele, Ntshongontshi’s “inter-ministerial relations” had started to fray. Unable to negotiate safe sex with her older partner or her boyfriend, she had to come up with a plan to keep her true love — and everyone else — safe.

She decided to become part of the Desmond Tutu Foundation’s PrEP programme for young women, collecting her tablets from the youth clinic every three months.

“I cannot just go to my boyfriend and say, ‘this time let’s start with a condom’. He’s going to have suspicions and I don’t want him to know that I am cheating,” she explains.

“So I started taking PrEP, so I can protect my partner.”

Watch: For many young women who walk through the centre’s doors, this will be their first introduction to the HIV prevention pill

On the outskirts of Cape Town, a young woman leaves home, locking the door behind her. She walks past the green-painted corrugated iron and pink roses of her neighbours’ homes. Then she stops to buy a half a loaf of bread and joins her friends at a picnic table under some trees to have lunch.

“[PrEP] is like a pregnancy prevention pill. If you take [birth control] every day you won’t fall pregnant,” she tells her friends.

“If you take PrEP every day, you won’t catch HIV. I use it because I want to be in control.”

For most women who join the Desmond Tutu Foundation’s PrEP programme, this film— played on tablets at the foundation’s youth centre — will be their first introduction to the HIV prevention pill.

South Africa is the second country on the continent to begin providing PrEP. But unlike Kenya, which rolled out the prevention pill to anyone who wanted it, South Africa chose to pilot PrEP first in groups at a high risk for contracting HIV.

By contrast, about half of men who had sex with men who were given the option of PrEP took it during the first year of the programme. In total, South Africa’s public PrEP rollout has started about 12 000 people on the prevention pill in its first three years — but less than a quarter of these people have been young women.

Whether or not young women start and stay on the HIV prevention pill may be less about facts and more about feelings. In 2015, Desmond Tutu foundation researchers conducted a small study among about a dozen young women just like Ntshongontshi about how they felt about possibly taking PrEP. The study’s participants were from Masiphumelele.

But the study, which was published in the journal AIDS and Behavior in 2018, also found that women were generally interested in preventing HIV and in the once-a-day pill — regardless of how they felt about their relationships.

Women in the Masiphumelele community also told Bhekisisa they were also keen to start PrEP because high levels of sexual and gender-based violence made them fear contracting HIV after being raped.

Understanding how women see their individual HIV risk is important, the deputy director of the Desmond Tutu HIV Foundation, Linda-Gail Bekker explains. Otherwise, it’s hard to speak to them about their lives and selling them on the idea of PrEP.

She continues: “Nobody wants to be thought of as a high-risk individual, right? It’s very stigmatising. What I think we want people to say is: ‘Do I have a risk of exposure to the HIV virus?’”

Part of destigmatising the HIV prevention pill may be a bit of a rebrand and getting more women to think of it not as a lifelong treatment but a short-term prevention method — like birth control.

“The best analogy for PrEP, in my opinion, is family planning,” Bekker says.

“As a woman … sometimes you’re not on contraception because you’re wanting to get pregnant. Sometimes you know you’re not going to want to get pregnant for weeks or years and then you might use a long-acting methodology like an implant.”

And because PrEP isn’t about treating an illness, women shouldn’t get it from clinics — places people go to when they’re sick.

“We need to find other avenues [for giving out PrEP], such as mobile clinics … because in a way we want to keep the health facilities for sick people,” Bekker says.

“These are not sick people; they are people who are well and they are seeking prevention.”

New pills, new moves: The Desmond Tutu HIV Foundation attracts young people to health services through its colourful mobile clinics and a centre that offers everything from tutoring to pool. (David Harrison)

The foundation, for instance, also distributes PrEP from their rainbow coloured mobile clinics called Tutu Teen Trucks. The vehicles reach young women between the ages of 16 and 25 in Cape Town areas such as Khayelitsha, Nyanga and Philippi.

And whether it’s a truck or a youth centre, young people want respectful spaces that work for them and around their lives, including school hours, Bekker says.

She argues that rebranding the HIV prevention pill for women is only a small part of getting it into their hands. There is a need for more widespread education on PrEP, not only among women but also among the healthcare workers who will need to sell women on the service to drive demand for it.

“We don’t know if we want to roll this out because we don’t get the impression that the population at large wants to use it.

“But we also know that the population at large won’t use something they don’t know about or are suspicious about. And we know from the ARV rollout or any new thing that comes into the public sector, people take a while to catch on.”

Nelisiwe Msomi was a health reporter at Bhekisisa. She holds a bachelors degree in journalism from the University of Johannesburg.
She is interested in seeing government policies go beyond paper and boardrooms, and see how they translate into action on the ground.
At Bhekisisa, Msomi sniffs around studies for solutions that can make access to healthcare better and efficient. If she is not writing the news, she is reading it.